By Chanté Solomon and Nicky Smith

Two years into the pandemic, COVID continues to require an “all hands-on deck” approach, causing a strain on resources, and exacerbating existing health disparities. For instance, from July 2019 to June 2020, the mortality rate for homeless New Yorkers – a group that already faces major barriers to accessing traditional systems –  increased by 52%. In response, Test & Trace evolved and expanded to include initiatives that address NYC’s ever-changing needs while refocusing on a core tenet of NYC H+H’s mission – “serving the underserved”. One of these initiatives is initiative is the Street Health Outreach & Wellness (SHOW) program.

In April 2021, SHOW launched with the intention of addressing the disparity in COVID-19 testing and access to vaccines among the homeless population of New York City. Emergency departments (EDs) have long acted as a catch-all for the health needs of the homeless community and have been a regular destination for that population, many of whom are not able to engage in regular primary care. This trend of homeless New Yorkers relying on hospital and emergency services for basic care continued throughout the pandemic, causing further strain on a struggling healthcare system.

A survey conducted in 2020 with homeless individuals who were found seeking care in various NYC EDs found that 69% of respondents did not have a regular doctor outside of the ED and 76% had visited the ED at least 10 times in the previous year. ED-only access limits care options and is often inadequate for this population of New Yorkers. To address this broader need of health service access, SHOW expanded beyond its COVID-19 scope to include additional services that cater to those who are unsheltered. In its ten month tenure, SHOW has provided 80,000 clinical services – both COVID related and otherwise, 8,000 physical goods – such as hygiene supplies, Narcan, and fentanyl testing kits – and 2,000 linkages to NYC H+H Primary Care Safety Net Clinics, harm reduction services, housing, and other social services.

In particular, non-COVID related clinical service offerings have grown over time to support the many needs of the homeless. For example, SHOW now administers flu tests and several vaccines including flu, Tdap and Hep A. Still, medical consultations such as wound care and well person checks are the most in demand non-COVID related clinical service. This is a testament to how SHOW has stepped in to fill the healthcare gap of the underserved.

SHOW offers these services through a fleet of six accessible buses, each of which have a roving team component consisting of an advanced practice provider (APP), a paramedic, and a Social Worker. Though SHOW is certainly not the first H+H mobile-based initiative, the roving team model is our differentiating factor and our key to patient engagement. While the buses remain stationary for the day, the roving teams canvass on foot throughout the area with the goal of increasing engagement with homeless individuals. This deployment strategy allows teams to meet patients where they are and reach individuals who may not be able or willing to come to the bus for services. Armed with backpacks full of supplies, roving teams provide all the same services as the stationary bus units. This dual bus and on-foot strategy allow SHOW to be more flexible when we approach and engage patients.

In addition to the dual outreach strategy, SHOW’s roving teams rely on a comprehensive care model, a data-informed deployment strategy, and a strong commitment to community-based organization (CBO) collaborations to run a balanced and successful program.

• Comprehensive care model: The diversity of experience and expertise amongst each member of the roving team ensures that they are prepared and equipped to support patients on an array of issues.
  • The Advanced Practice Provider (usually a Nurse Practitioner or a Physician’s Assistant) performs medical assessments for clients. Additionally, the APP uses these assessments to determine client eligibility for Safety Net and Bupe clinic The APP is responsible for connecting clients to these two services and manages the relationship with the intake staff of our partner organizations who run those programs.
  • The paramedic, and the APP, carry backpacks stocked with all vaccines to administer to clients. The paramedic also assists with medical consults and takes point on any emergency medical care situations.
  • The Social Worker (SW) is typically the first person who makes contact with potential clients and tends to have ongoing relationships with repeat patients. In addition to providing hygiene, narcan, and fentanyl kits, SWs engage clients in conversations about their mental health, substance use, clinical, housing, and financial needs. SWs then utilize various methods and medical assessments from the APP to secure service referrals for patients at local organizations. SHOW SWs are licensed and many have additional experience in other fields, such as criminal justice and emergency care, that prove to be useful when engaging with SHOW’s clients.

  The complementary roles of this triumvirate allow the team to provide comprehensive care which supports the often inseparable clinical and social needs of patients.

• Data-informed deployment: SHOW uses both quantitative and qualitative data to inform our decisions on roving team locations. We regularly monitor our data points on engagement and overall service trends in particular areas, then synthesize those quantitative measures with more qualitative information to develop a more complete picture of our work.

  Empirical data points include input from our city partners and observations from our teams in the field, including migration patterns of patients and effects of weather, time of day, and police presence on patient engagement. Incorporating various types of data into our decision-making allows us to develop dynamic strategies for deploying our roving teams, increasing our visibility and impact with those who would most benefit from our services. Beyond typical “street-level” outreach, current roving routes include transit hub areas, subway stations – both on the platforms and through the turnstiles – and city parks.

• CBO Collaboration: SHOW recognizes the important role CBOs play in connecting with and instilling change within NYC communities. Therefore, SHOW frequently partners with CBOs for guidance and support in effectively servicing the needs of the communities in which we work. SHOW maintains a robust “rolodex” of community partners and works diligently to maintain open channels of communication. Because many of these organizations were established well before SHOW, not only do they lend general expertise on tactics and strategy, but they also have more personal and long-standing connections with clients which can help to bolster the connection made between these clients and SHOW’s teams.

  CBO collaboration comes in many forms and includes strategies such as mutual referrals of patients, mutual flyer distribution, or working on-site and sometimes roving together. These strategies have proven to be particularly useful for a roving team’s success as they encounter more people from within the population.

SHOW’s roving teams have done their part in providing much needed services to New Yorkers and relieving some of the burden on our healthcare system. The roving teams alone have provided close to 2,000 medical consultations. This success can be attributed to SHOW’s ability and willingness to experiment with various operational models

Below are a few examples of how the SHOW program has evolved in response to what we have learned on the ground:

• Reassigning Social Workers: SHOW reassigned the SWs from the mobile units to the roving teams because feedback indicated that high-needs patients were more likely to engage with the roving team. SWs were able to carry more items like food, water, and other materials, and hand resources directly to the patients as opposed to patients having to ask at a bus. Since this reassignment, SWs have become a permanent staple of our roving teams.
• Adding Roving Cars In the winter months, we provided the roving teams with cars to provide warmth for the staff, to carry and store more equipment (e.g., mylar blankets, food, etc.), and to find homeless patients who shifted locations to find warmth. With this addition, our teams found many of our repeat patients who moved from park-to-park.

As we continue to respond to the needs of the community, SHOW’s adaptability allows us to innovate as we respond to New Yorkers in high need of comprehensive care. We’re continuously adding services to meet needs, and are continuing to improve as we move forward.